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Not a day goes by without news of the increasing financial inequality in the UK - whether it is the old, the young or the unemployed. It is widely reported that wealth, and how it is distributed, has changed over the last two or three decades, and this trend is likely to continue. But what impact might this be having on eye care?

You may be forgiven for speculating that eye care is immune from such inequality: there should not be a problem, as the young, the old and those on low incomes are all able to access free eye care paid for by the state. The recent College See The Gap report questions this assertion and calls for more research into eye health inequality.

The inequality is not about access to an expensive wonder drug or advanced diagnostic test, but simply to correction for refractive error. In other words, there is inequality in access to sight tests and glasses. According to work by Prof Darren Shickle, and other public health researchers, the key issue preventing people in deprived areas accessing services seems to be their perception of optometry. Patients believe that a trip to the optometrist could prove costly and may involve hard sell of glasses. This perception, whether true or not, means that patients simply do not attend for sight tests. In consequence, they miss not only correction for refractive error, but the important ocular health check provided by the sight test. This in turn can result in late diagnosis of pathology and poorer outcomes for the patient.

Anecdotally, this broadly fits with my experience. When practising in a generally affluent, educated area like Cambridge, patients reliably attended regular appointments with most referrals being made at an early pre-symptomatic stage. Contrarily, in the more deprived communities of East Anglia, the picture seems quite different. It is quite remarkable to count the number of patients presenting for their first ever sight test who are only there due to a clinical problem or more advanced pathology.

The report, which ultimately calls for more research into eye health inequality, reviews evidence from a number of studies which attempt to estimate access to eye care in deprived communities. The various area-specific studies that examined practice location versus sight test uptake, suggest that varying GOS contract arrangements can have an effect on businesses remaining afloat in deprived communities. Add the negative perceptions held by many patients in these communities, and you have a dangerously low take-up of eye examinations. This leaves us with concentrated pockets of missed asymptomatic ocular pathology and patients’ quality of life affected by uncorrected refractive error.

The report, which ultimately calls for more research into eye health inequality, reviews evidence from a number of studies which attempt to estimate access to eye care in deprived communities.

Following the evidence, the report suggests a 10 point plan to close this gap, including enhanced GOS in deprived areas. One potential option for accommodating this might be targeted provision of a sight-test-only, non dispensing service. This would break the link between the perceived cost of new glasses and attending for a sight test, enabling patients to access services according to need.

The report asserts that the current financial model of cross-subsidising health care through glasses sales may not be working for the poorest people within our society. With the growing market share of online providers, the viability of cross subsidy itself is indeed questionable, there has been little recognition of the implications of this on the wider NHS GOS provision in England. It is imperative that we as a profession consider how new pathways for accessing eye care might be created, avoiding the barriers that exist at present. For as the gap between rich and poor in the UK grows ever bigger, so too will the numbers deterred by perceived cost from accessing eye care service.

Daniel graduated from Anglia Ruskin University, where he won the Haag Strait prize for best dissertation. Before joining the College, he was Managing Director of an independent practice in Cambridge and a visiting clinician at Anglia Ruskin University. He has also worked as a senior glaucoma optometrist with Addenbrooke’s Hospital in Cambridge, with Newmedica across East Anglia and as a diabetic retinopathy screening optometrist. Daniel was a member of Cambridgeshire LOC from 2007 to 2015 and a member of the College of Optometrists’ Council from 2009 to 2014, representing its Eastern region.

He is Clinical Adviser to the College of Optometrists for three days each week, dividing the remainder of his time between community practice, glaucoma shared care clinics and providing consultancy to Specsavers. Daniel is a passionate advocate of the profession of optometry, committed to supporting all members of the profession and ensuring patient care is always at the heart of optometry. He was awarded Fellowship by Portfolio in December 2018.